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A Duluth nursing home has been cited for neglect after state investigators found that four of its nurses failed to attempt resuscitation last May of a patient who was found unresponsive and died.

The 170-bed nursing home, Chris Jensen Health and Rehabilitation Center, which has a history of regulatory violations, also lacked a system to ensure that patients’ medical wishes were followed when they are found without a pulse and not breathing, according to a Minnesota Department of Health investigation that was made public Wednesday.

The patient, who is not identified in the report, had a physician’s order for lifesaving treatment, also known as a POLST, directing that cardiopulmonary resuscitation (CPR) be performed if the resident had no pulse and was not breathing. Despite the physician’s order, four nurses who cared for the patient failed to provide basic life support after finding the person was unresponsive in her bed, investigators found. One of the nurses assumed the patient did not request CPR, while another nurse knew the patient required resuscitation but felt it was too late to start emergency care, according to the state investigation. A third nurse who discovered the patient was “too upset to do anything, including CPR,” the investigators said. A nurse practitioner told investigators that she gave an order to not start CPR, after learning that the patient was “cold, stiff and had been dead for a while,” the state report said.

The patient had lived at the nursing home for more than a year and had diagnoses that included respiratory failure and cellulitis, a bacterial skin infection.

The Health Department determined that the nurses’ failure posed an immediate health risk to 45 other patients at the nursing home who had requested CPR in case of need. The facility has since corrected the violation by educating all its nurses on CPR and emergency response, and by conducting mock emergency drills with staff, the state report said. In addition, all resident medical records were reviewed to ensure that each patient had a physician’s order for lifesaving treatment, according to the state report.

Amy Porter, executive director of the facility, which is owned by Health Dimensions Group of Minneapolis, declined to discuss specifics of the patient’s death and steps taken to address the state’s concerns, but said in a written statement that the facility is committed to providing quality care. “At all times, the health, safety and privacy of our residents and staff are our first priority,” she said.

Over the past three years, health inspectors have cited the Chris Jensen nursing home for more than 30 violations of health, safety and quality of life standards, including failure to take adequate steps to prevent maltreatment and abuse, according to the federal government’s Nursing Home Compare website. In 2016, the nursing home was fined nearly $24,000, and was temporarily blocked by federal regulators from receiving new Medicare and Medicaid payments, for multiple deficiencies that have since been corrected, federal records show.

Chris Serres • 612-673-4308 Twitter: @chrisserres